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Zhao Y, Zhu Y, Lu Y, Li F, Jiang C. Long-term outcomes of shoulder hemiarthroplasty for acute proximal humeral fractures. INTERNATIONAL ORTHOPAEDICS 2023; 47:1517-1526. [DOI: 10.1007/s00264-023-05746-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
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Cassart Masnou E, Ruiz Macarrilla L, Mora Solé E, García Perdomo D, Pérez Andrés R. Is the Position and Union of the Tuberosities Assessable by Means of the Simple Radiograph After Reverse Shoulder Arthroplasty for Complex Proximal Humerus Fractures? J Shoulder Elb Arthroplast 2023; 7:24715492231152149. [PMID: 36727142 PMCID: PMC9884950 DOI: 10.1177/24715492231152149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 12/12/2022] [Accepted: 01/05/2023] [Indexed: 01/27/2023] Open
Abstract
Background The assessment of tuberosity position and union in reverse shoulder arthroplasty (RSA) for complex proximal humerus fractures (PHF) has been carried out by means of routine simple radiographs. To evaluate the interobserver agreement and intraobserver reproducibility of the simple radiograph in comparison to the CT scan. Methods The position and consolidation of the tuberosities in 2 radiographic projections and in a CT scan of 32 consecutive patients operated on a RSA for PHF was assessed by 5 observers. Interobserver agreement and intraobserver reproducibility in both imaging tests were also assessed. Results The interobserver agreement for the greater tuberosity position was 0.52 in the simple radiograph and 0.45 in the CT scan. For the greater tuberosity union, agreement was moderate in the simple radiograph (0.52), but fair in the CT scan (0.35). For the lesser tuberosity position and union, the agreement was fair in the radiograph and poor in the CT scan. Conclusion Only moderate agreement was observed in the assessment of the position and union of the tuberosities in the RSA for PHF in the simple radiograph and no improvement in it was seen for the 2D CT scan.
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Affiliation(s)
- Elisa Cassart Masnou
- Hospital Universitari Germans Trias i Pujol,
Barcelona, Spain,Elisa Cassart Masnou, Crta Canyet s/n
Orthopaedic Surgery Department, Hospital Germans Trias i Pujol, 08916 Badalona,
Barcelona, Spain.
| | | | - E Mora Solé
- Hospital Universitari Germans Trias i Pujol,
Barcelona, Spain
| | | | - R Pérez Andrés
- Hospital Universitari Germans Trias i Pujol,
Barcelona, Spain
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Grassi FA, Alberio R, Ratti C, Surace MF, Piazza P, Messinese P, Saccomanno MF, Maccauro G, Murena L. Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont. Orthop Rev (Pavia) 2020; 12:8659. [PMID: 32913595 PMCID: PMC7459385 DOI: 10.4081/or.2020.8659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 11/22/2022] Open
Abstract
Shoulder replacement is indicated for the surgical treatment of proximal humeral fractures in elderly patients, when severe comminution and osteoporosis jeopardize the chances of success of any fixation technique. Two different implants are available for this purpose: anatomical hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA). HA for fractures was popularized by Charles Neer in the ‘50s and for several decades remained the only reliable implant for these injuries. However, many authors reported inconsistent results with HA as a consequence of the high rate of tuberosity and rotator cuff failure. In 1987, Paul Grammont designed the first successful RTSA, which was the end result of a long thought process on functional surgery of the shoulder. This implant was initially used to treat cuff tear arthropathy and shoulder pseudoparalysis, but indications have gradually expanded with time. Since RTSA does not rely on a functional cuff for shoulder elevation, it was felt that results in fractures could be improved by this prosthesis. In this study, the salient features of these implants are described to understand the rationale behind both approaches and highlight their pros and cons. Several clinical studies comparing HA vs RTSA for proximal humeral fractures have been published during the last two decades. A literature review is carried out to analyze and compare outcomes of both implants, analyzing clinical results, radiographic findings and complications. The final goal is to provide an overview of the different factors to consider for making a choice between these two prostheses.
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Affiliation(s)
- Federico A Grassi
- Orthopaedic and Trauma Unit, Department of Health Sciences, University Hospital University of East Piedmont, Novara
| | - Riccardo Alberio
- Orthopaedic and Trauma Unit, Department of Health Sciences, University Hospital University of East Piedmont, Novara
| | - Chiara Ratti
- Orthopaedic and Trauma Unit, Department of Medicine, Surgery and Health Sciences, University Hospital University of Trieste
| | - Michele F Surace
- Interdisciplinary Research Centre for Pathology and Surgery of the Musculoskeletal System, Department of Biotechnology and Life Sciences, University of Insubria, Varese
| | - Piero Piazza
- Orthopaedic Institute, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Piermarco Messinese
- Orthopaedic Institute, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Giulio Maccauro
- Orthopaedic Institute, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Murena
- Orthopaedic and Trauma Unit, Department of Medicine, Surgery and Health Sciences, University Hospital University of Trieste
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Torrens C, Alentorn-Geli E, Mingo F, Gamba C, Santana F. Reverse shoulder arthroplasty for the treatment of acute complex proximal humeral fractures: Influence of greater tuberosity healing on the functional outcomes. J Orthop Surg (Hong Kong) 2019; 26:2309499018760132. [PMID: 29486672 DOI: 10.1177/2309499018760132] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To investigate the influence of greater tuberosity healing on the functional outcomes of reverse shoulder arthroplasty (RSA) for the treatment of acute complex proximal humeral fractures (PHFs), and to investigate the influence of patient- and surgery-related factors in the healing of the greater tuberosity. METHODS Retrospective study including 41 consecutive PHFs treated using RSA with minimum 2-year follow-up. In all the cases, tuberosities were reattached with a standardized technique. All the patients were assessed at the last follow-up with constant score. Body mass index, surgery delay, comorbidities, polyethylene size, glenosphere size, overhanging of glenosphere, and scapular notch were recorded, and their influence in final constant score and in greater tuberosity healing was analyzed. RESULTS Mean final constant score was of 60.7 points (standard deviation (SD) = 9.9). Greater tuberosity healed in proper position in 68% of the cases. There were no significant differences in constant score between patients with (mean = 61; SD = 9.5) and without (mean = 61; SD = 11.3) the healing of greater tuberosity. All patients scored above 90° in forward elevation. Scapular notch was reported in 14.6% of the cases. Age significantly affected the constant score ( p = 0.008). Comorbidities significantly interfered with greater tuberosity healing ( p = 0.03). There was one reoperation after dislocation. CONCLUSION In spite of expecting good functional outcome with low complication rate after RSA for acute PHFs, the influence of greater tuberosity healing on shoulder function could not be demonstrated. The presence of comorbidities, but not age or gender, negatively influenced the healing of the greater tuberosity.
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Affiliation(s)
- Carlos Torrens
- 1 Department of Orthopaedic Surgery and Traumatology, Parc de Salut Mar - Hospital del Mar & Hospital de l'Esperança, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Eduard Alentorn-Geli
- 2 Fundación García-Cugat, Barcelona, Spain.,3 Artroscopia GC, SL, Hospital Quirón, Barcelona, Spain.,4 Mutualidad Catalana de Futbolistas, Federación Española de Fútbol, Barcelona, Spain.,5 Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Felipe Mingo
- 1 Department of Orthopaedic Surgery and Traumatology, Parc de Salut Mar - Hospital del Mar & Hospital de l'Esperança, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Carlo Gamba
- 1 Department of Orthopaedic Surgery and Traumatology, Parc de Salut Mar - Hospital del Mar & Hospital de l'Esperança, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Fernando Santana
- 1 Department of Orthopaedic Surgery and Traumatology, Parc de Salut Mar - Hospital del Mar & Hospital de l'Esperança, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
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Jain NP, Mannan SS, Dharmarajan R, Rangan A. Tuberosity healing after reverse shoulder arthroplasty for complex proximal humeral fractures in elderly patients-does it improve outcomes? A systematic review and meta-analysis. J Shoulder Elbow Surg 2019; 28:e78-e91. [PMID: 30593437 DOI: 10.1016/j.jse.2018.09.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/29/2018] [Accepted: 09/05/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus in older patients. Anatomic tuberosity healing in RSA has been recognized to restore better shoulder function. We compared the reported clinical and functional outcomes of RSA in proximal humeral fractures with and without tuberosity healing. METHODS We performed a systematic review of literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials. We included all studies with RSA for proximal humeral fractures in patients older than 60 years and compared outcomes based on tuberosity healing with minimum follow-up of 12 months. RESULTS Seven studies met the inclusion criteria. A total of 381 patients (382 shoulders) were identified. There were 53 men (18.3%) and 236 women (81.7%), with mean age of 76.83 years (range, 74-81 years). Mean follow-up duration was 29.84 months (range, 24-90 months), and the mean rate of greater tuberosity healing was 70.5%. Patients with healed tuberosity had significantly better active forward flexion (134.1° vs. 112.5°, P < .05), abduction (114.8° vs. 95.1°, P < .05), external rotation with elbow by the side (27.8° vs. 7.6°), and mean Constant score (63.5 vs. 56.6, P < .05) than with those with nonhealed tuberosity. CONCLUSION The RSA group with healed greater tuberosity showed better range of motion, especially forward flexion and external rotation and Constant scores, compared with the nonhealed greater tuberosity group. Tuberosity healing may influence overall shoulder function after RSA for proximal humeral fractures in the elderly, and this needs verification with future prospective studies.
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Affiliation(s)
- Nimesh P Jain
- Department of Trauma and Orthopaedics, North Cumbria University Hospitals National Health Service Trust, Carlisle, Cumbria, UK.
| | - Syed S Mannan
- Department of Trauma and Orthopaedics, North Cumbria University Hospitals National Health Service Trust, Carlisle, Cumbria, UK
| | - Ramasubramanian Dharmarajan
- Department of Trauma and Orthopaedics, North Cumbria University Hospitals National Health Service Trust, Carlisle, Cumbria, UK
| | - Amar Rangan
- Department of Orthopaedics, The James Cook University Hospital, South Tess National Health Service Foundation Trust, Middlesbrough, UK; Faculty of Medical Sciences and Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Department of Health Sciences, University of York, York, UK
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Cementless and locked prosthesis for the treatment of 3-part and 4-part proximal humerus fractures: prospective clinical evaluation of hemi- and reverse arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:301-308. [DOI: 10.1007/s00590-017-1926-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
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Obert L, Saadnia R, Loisel F, Uhring J, Adam A, Rochet S, Clappaz P, Lascar T. Cementless anatomical prosthesis for the treatment of 3-part and 4-part proximal humerus fractures: cadaver study and prospective clinical study with minimum 2 years followup. SICOT J 2016; 2:22. [PMID: 27194107 PMCID: PMC4867887 DOI: 10.1051/sicotj/2016011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 02/17/2016] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The purpose of this study was to evaluate the functional and radiological outcomes of a cementless, trauma-specific locked stem for 3- and 4-part proximal humeral fractures. MATERIALS AND METHODS This study consisted of two parts: a cadaver study with 22 shoulders and a multicenter prospective clinical study of 23 fracture patients evaluated at least 2 years after treatment. In the cadaver study, the locked stem (Humelock(TM), FX Solutions) and its instrumentation were evaluated. In the clinical study, five senior surgeons at four different hospitals performed the surgical procedures. An independent surgeon evaluated the patients using clinical (Constant score, QuickDASH) and radiological (X-rays, CT scans) outcome measures. RESULTS The cadaver study allowed us to validate the height landmarks relative to the pectoralis major tendon. In the clinical study, at the review, abduction was 95° (60-160), forward flexion was 108° (70-160), external rotation (elbow at body) was 34° (0-55), the QuickDASH was 31 (4.5-59), the overall Constant score was 54 (27-75), and the weighted Constant score was 76 (31.5-109). DISCUSSION This preliminary study of hemiarthroplasty (HA) with a locked stem found results that were at least equivalent to published series. As all patients had at least a 2-year follow-up, integration of the locked stem did not cause any specific complications. These results suggest that it is possible to avoid using cement when hemiarthroplasty is performed for the humeral stem. This implant makes height adjustment and transosseous suturing of the tuberosities more reproducible.
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Affiliation(s)
- Laurent Obert
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Orthopaedic, Traumatology and Hand Surgery Unit, Research Unit: EA 4268 I4S – IFR 133 INSERM, CHRU Besançon, University of Bourgogne Franche-Comté, Bd Fleming 25030
Besançon Cedex France
| | - Rachid Saadnia
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Orthopaedic, Traumatology and Hand Surgery Unit, Research Unit: EA 4268 I4S – IFR 133 INSERM, CHRU Besançon, University of Bourgogne Franche-Comté, Bd Fleming 25030
Besançon Cedex France
| | - François Loisel
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Orthopaedic, Traumatology and Hand Surgery Unit, Research Unit: EA 4268 I4S – IFR 133 INSERM, CHRU Besançon, University of Bourgogne Franche-Comté, Bd Fleming 25030
Besançon Cedex France
| | - Julien Uhring
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Orthopaedic, Traumatology and Hand Surgery Unit, Research Unit: EA 4268 I4S – IFR 133 INSERM, CHRU Besançon, University of Bourgogne Franche-Comté, Bd Fleming 25030
Besançon Cedex France
| | - Antoine Adam
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Orthopaedic, Traumatology and Hand Surgery Unit, Research Unit: EA 4268 I4S – IFR 133 INSERM, CHRU Besançon, University of Bourgogne Franche-Comté, Bd Fleming 25030
Besançon Cedex France
| | - Séverin Rochet
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Orthopaedic, Traumatology and Hand Surgery Unit, Research Unit: EA 4268 I4S – IFR 133 INSERM, CHRU Besançon, University of Bourgogne Franche-Comté, Bd Fleming 25030
Besançon Cedex France
| | | | - Tristan Lascar
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Orthopedic, Traumatology, and Hand Surgery Unit, Hopital Princesse Grace de Monaco Monaco Principauté de Monaco
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Reverse shoulder arthroplasty for acute proximal humeral fractures in the geriatric patient: results, health-related quality of life and complication rates. INTERNATIONAL ORTHOPAEDICS 2016; 40:771-81. [PMID: 26780717 DOI: 10.1007/s00264-015-3085-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Reverse shoulder arthroplasty (RSA) in fractures is especially indicated in patients of advanced age, although the influence of age on functional outcomes, health-related quality of life (HRQoL) and complication rate is unknown. We hypothesized that complication rate would decrease in the geriatric population because of their reduced activity, improving the perceived HRQoL. METHODS Retrospective study of 42 patients with proximal humeral fractures treated with RSA, divided into two groups: <80 years (<80y)(n = 16) and ≥80 years (≥80y)(n = 26). The assessment tools used were radiological images (functional outcome) with the Constant-Murley score(CMS); disabilities of the arm, shoulder and hand (DASH) score; and HRQoL with the EQ-5D index. Mean follow-up time was 32.6 months. RESULTS Mean CMS adjusted for age and sex (R-CMS) was 68 % ± 29 %. Patients in the ≥80y group had a lower total CMS, 33 vs 64 (p = 0.027). Mean active range of motion at 24 months <80y/≥80y was: forward flexion: 126°/110°; abduction: 117°/105°; external rotation: 22°/20°; and internal rotation: L3/sacrum. Mean EQ-VAS was 74 ± 16 in the <80y group, and 63 ± 12.6 in the ≥80y group. Mean DASH was 29.5 ± 9.2. The EQ-5D "self-care" item in the >80y group was the most affected. The "pain/discomfort" item was lower for the two age groups than for the reference population. There were 9.5 % complications: one prosthesis dislocation, one periprosthetic fracture and two surgical wound haematoma. CONCLUSIONS Our results indicate that age is a critical factor for RSA success. Lower functional outcomes have been obtained in patients older than 80y, although the EQ-5D results in our sample were similar or even better than the referred population. LEVEL OF EVIDENCE Level III.
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Chalmers PN, Slikker W, Mall NA, Gupta AK, Rahman Z, Enriquez D, Nicholson GP. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg 2014; 23:197-204. [PMID: 24076000 DOI: 10.1016/j.jse.2013.07.044] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 07/02/2013] [Accepted: 07/16/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Significant controversy surrounds optimal treatment of displaced 4-part proximal humeral fractures. Reverse total shoulder arthroplasty (RTSA) has recently been proposed as an alternative to hemiarthroplasty (HA) and open reduction-internal fixation (ORIF). Several authors have questioned the additional implant cost for RTSA. The purpose of this study was to compare outcomes and cost of RTSA, HA, and ORIF. MATERIALS AND METHODS We prospectively evaluated patients who underwent RTSA for displaced 3- and 4-part proximal humeral fractures and then retrospectively developed age- and sex-matched control groups with 3- and 4-part proximal humeral fractures who underwent HA and ORIF. Range of motion including active forward elevation and external rotation and time to achieve active forward elevation >90° were recorded. American Shoulder and Elbow Surgeons (ASES), Short-Form 12-item (SF-12), and Simple Shoulder Test (SST) scores were recorded. In addition, treatment cost was assessed by Medicare data and implant list prices. RESULTS This study enrolled 27 patients; 9 underwent RTSA, 9 HA, and 9 ORIF. Minimum follow-up was 1 year. No significant differences were seen in SST, ASES, or SF-12 scores. Significantly more patients achieved >90° of active forward elevation after RTSA (P = .012). RTSA provided significant cost savings to Medicare compared with HA and ORIF (P = .002.) CONCLUSION In this case-control study, RTSA appears to provide superior range of motion earlier and more predictably than HA and ORIF, with significant cost savings to Medicare.
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Affiliation(s)
- Peter N Chalmers
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
| | - William Slikker
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Anil K Gupta
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Zain Rahman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Daniel Enriquez
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Tepass A, Rolauffs B, Weise K, Bahrs SD, Dietz K, Bahrs C. Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009. Patient Saf Surg 2013; 7:34. [PMID: 24268107 PMCID: PMC4176190 DOI: 10.1186/1754-9493-7-34] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 11/05/2013] [Indexed: 12/16/2022] Open
Abstract
Background The optimal treatment of complex, displaced proximal humeral fractures is controversial. A systematic literature review of the time period from 1970 to 2009 was conducted. The purpose was to evaluate the clinical success and complications of the available treatment modalities to determine specific treatment recommendations for the different fracture patterns. Methods The databases (PubMed/EMBASE) were searched for the time period (01/1970–09/2009). Study quality, treatment modalities, classification, outcome scores and complications of 200 publications including 9377 patients were analyzed. Interventions were compared by analysis of variance with subsequent Tukey’s-test. Complication rates among methods were compared by using Pearson’s-chi-square-test and pairwise comparisons using Fisher’s-two-tailed-exact-test. Results Hemiarthroplasty, angle-stable plate and non-operative treatment were used for 63% of the follow-up-patients. For 3- and 4-part fractures, patients with hemiarthroplasty [3-Part: 56.4 (lower/upper 95% confidence interval (CI): 43.3-68.7); 4-Part: 49.4 (CI: 42.2-56.7)] received a lower score than different surgical head-preserving methods such as ORIF [3-Part: 82.4 (CI: 76.6-86.9); 4-Part: 83.0 (CI:78.7-86.6)], intramedullary nailing [3-Part: 79.1 (CI:74.0-83.4)] or angle-stable plates [4-Part: 66.4 (CI: 59.7-72.4)]. The overall complication rate was 56%. The most common complications were fracture-displacement, malunion, humeral head necrosis and malreduction. The highest complication rates were documented for conventional plate and hemiarthroplasty and for AO-C, AO-A, for 3- and 4-part fractures. Only 25% of the data were reported with detailed classification results and the corresponding outcome scores. Discussion Despite the large amount of patients included, it is difficult to determine adequate recommendations for the treatment of proximal humeral fractures because a relevant lack of follow-up data impaired subsequent analysis. For displaced 3- and 4-part fractures head-preserving therapy received better outcome scores than hemiarthroplasty. However, a higher number of complications occurred in more complex fractures and when hemiarthroplasty or conventional plate osteosynthesis was performed. Thus, when informing the patient for consent, both the clinical results and the possibly expected complications with a chosen treatment modality should be addressed.
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Affiliation(s)
- Alexander Tepass
- Department of Radiology, Eberhard-Karls University, Tübingen, Germany.
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11
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Innocenti M, Carulli C, Civinini R, Matassi F, Tani M, Muncibì F. Displaced fragility fractures of proximal humerus in elderly patients affected by severe comorbidities: percutaneous fixation and conservative treatment. Aging Clin Exp Res 2013; 25:447-52. [PMID: 23760947 DOI: 10.1007/s40520-013-0063-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 02/04/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Proximal humerus is a common site of fracture in elderly patients, mainly related to bone fragility. Comorbidities are often present in these patients and may limit the surgical options. Not or minimal invasive treatments are commonly indicated however with variable results. The authors present their experience with conservative approach and percutaneous fixation by K-wires, focusing on their indications and main advantages on this population: mini-invasivity, acceptable reduction and recovery, and low costs. METHODS A study group of 51 consecutive patients with a mean age of 75.5 and affected by severe comorbidities (mainly cardiac, circulatory, pneumologic, neurologic, metabolic, and nephrologic pathologies) were evaluated clinically (ASA score, VAS, muscular strength, Constant-Murley score), and with radiologic analysis: 28 patients were treated by percutaneous fixation, while 23 subjects were treated conservatively. RESULTS Fractures treated by K-wires fixation healed after a mean interval of 8.2 weeks in all fractures but one, with improvements in mean Constant-Murley score (up to 80.6 points), in mean VAS (2.9), in muscular strength (4.1), and in range of motion. Fractures treated by brace healed in a mean time of 10.2 weeks. Mean Constant-Murley score improved to 76.4 points, VAS to 3.0, muscular strength to 3.8 points, and significant recovery of range of motion. CONCLUSIONS Results of the study confirm that both percutaneous fixation and conservative treatment may represent suitable options for proximal humerus fragility fractures in elderly patients, not candidated to open surgery for severe associated comorbidities. LEVEL OF EVIDENCE IV (case series study).
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Affiliation(s)
- Massimo Innocenti
- Orthopaedic Clinic, University of Florence, Largo P. Palagi 1, 50139 Florence, Italy
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12
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Okike K, Lee OC, Makanji H, Harris MB, Vrahas MS. Factors associated with the decision for operative versus non-operative treatment of displaced proximal humerus fractures in the elderly. Injury 2013; 44:448-55. [PMID: 23022082 DOI: 10.1016/j.injury.2012.09.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 09/04/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND In the management of displaced proximal humerus fractures in the elderly, wide variation has been documented. However, no prior study has investigated the factors that currently lead surgeons to treat patients with surgical fixation, arthroplasty or non-operative management. The purpose of this study was to identify the factors associated with treatment selection in the management of displaced proximal humerus fractures in individuals over the age of 60 years. To this end, we conducted a retrospective review of all such injuries that presented to our two level-I trauma centres between 2006 and 2009. PATIENTS AND METHODS From our prospectively collected trauma database, we identified 229 displaced proximal humerus fractures that met all inclusion and exclusion criteria. Data were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for treatment. The choice of management was recorded, and logistic regression was used to identify factors associated with the decision for treatment. RESULTS In the multivariate analysis, the predictors of operative intervention as opposed to non-operative treatment were younger patient age (p = 0.038), associated orthopaedic injuries requiring surgery (p = 0.012), higher Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification (p = 0.012), translation-type displacement (p = 0.0012) and associated glenohumeral dislocation (p = 0.0006). In addition, shoulder and upper extremity specialists were found to choose operative intervention significantly more frequently than orthopaedic trauma specialists (49.1% vs. 26.1%, adjusted relative risk (RR) 1.96, p = 0.012). Factors associated with the decision for arthroplasty as opposed to fixation were higher Charlson score (p = 0.045), higher Neer classification (p = 0.012), and higher AO classification (p = 0.0097). CONCLUSIONS In this study of displaced proximal humerus fractures in the elderly, the decision for surgery was influenced by the patient's age, the presence of associated orthopaedic injuries, the severity of the fracture and the presence of an associated glenohumeral dislocation. In addition, treatment by a shoulder or upper extremity specialist (as opposed to an orthopaedic trauma specialist) was associated with a higher likelihood of operative intervention. Further investigation into the resultant clinical outcomes is required to determine whether the use of these characteristics to select operative candidates is appropriate and beneficial for patients.
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Affiliation(s)
- Kanu Okike
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Gallinet D, Adam A, Gasse N, Rochet S, Obert L. Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. J Shoulder Elbow Surg 2013; 22:38-44. [PMID: 22705317 DOI: 10.1016/j.jse.2012.03.011] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 02/29/2012] [Accepted: 03/05/2012] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Reverse shoulder arthroplasty in complex shoulder fractures is now a common practice. Unfortunately, loss of rotation is observed when tuberosity excision is used, impairing function and patient satisfaction. The purpose of this study was to evaluate the advantage of tuberosity repair in terms of the functional result. MATERIALS AND METHODS We reviewed 41 patients, with a mean age at trauma of 76.9 years, at a mean follow-up of 24 months. Tuberosities were repaired in 27 patients and totally removed in the other 14 cases. RESULTS Two-thirds of the repaired tuberosities consolidated in anatomic position. We compared a group with tuberosity healing in anatomic position versus a group without repair and with malunion or nonunion of the tuberosities. In the first group, all sectors of motion, especially external rotation (49° vs 10°), were improved and both Constant scores (65 vs 50) and Disabilities of the Arm, Shoulder and Hand scores (30 vs 40) were significantly better. CONCLUSION Management of complex fractures of the superior extremity of the humerus by reverse shoulder arthroplasty is an accepted approach, but such treatment is restricted to elderly patients. Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant. However, their consolidation should be anatomic; otherwise, the result is impaired by the lack of rotation. Nonunion or malunion does not lead to a functional disaster, as is sometimes the case with hemiarthroplasty without tuberosity healing.
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Affiliation(s)
- David Gallinet
- Saint Vincent Private Hospital, 33 Chemin des Tilleroyes, Besançon, France.
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Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively. J Orthop Trauma 2011; 25:581-7. [PMID: 21886006 DOI: 10.1097/bot.0b013e318210ed2f] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Functional and quality-of-life outcomes of conservatively treated proximal humeral fractures. DESIGN Prospective study. SETTING University orthopedic department at a hospital. PATIENTS/PARTICIPANTS Seventy consecutive patients between the ages of 60 and 85 years. INTERVENTION Conservative treatment. MAIN OUTCOME MEASUREMENTS Functional outcome measured according to the Constant score, quality of life assessed using EuroQol-5D, and fracture pattern analyzed with x-ray and computed tomography scan. RESULTS : All fractures consolidated uneventfully with no loss of reduction in either group. Four-part fractures obtained the worst functional results (33.66) followed by three-part fractures (54.64) and finally two-part fractures (65.88 and 71). Mild pain was expected in three- and four-part fractures, whereas two-part fractures achieved near complete pain relief. Nondisplaced fractures obtained a final Constant score of 73.58 and displaced fractures a score of 59.41 with significant differences in all Constant score items with the exception of external rotation. Although patients older than 75 years scored lower (54.63) than those younger than 75 years (70.83), there was no difference in the quality-of-life perception. CONCLUSION Conservative treatment of proximal humeral fractures in those patients older than age 75 years provides good pain relief with limited functional outcome. Despite limited functional outcome, this appears to have no effect on the quality-of-life perception in the population studied. Four-part fractures present the worst results and treatment options may need to be discussed with the patient to adjust treatment to patient expectations.
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Abstract
Proximal humerus fracture devascularizing the humeral head may require management by prosthesis. Hemiarthroplasty is a logical attitude in such cases, but analysis of functional results and complications has identified a certain number of risk factors limiting indications. Strict analysis of patient characteristics and of fracture type is an essential prerequisite to deciding against treatment by immobilization or osteosynthesis. Results in hemiarthroplasty are primarily dependent on respecting the rules of the art, which aim at stable anatomic osteosynthesis of the surrounding structures so as to restore normal shoulder function. The critical steps are the adjustment of implant height and retroversion, reduction and fixation of tuberosities and good management of the postoperative course. The recent development of fracture-dedicated shoulder implants should improve results. In elderly patients, when local conditions are unsuitable to hemiarthroplasty, a reverse prosthesis may be used, with an adapted surgical technique. Whatever the type of prosthesis, implantation for proximal humerus fracture is a demanding operation with definitive impact on the functional evolution of the shoulder.
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